Sports Injuries and Concussions in Children

May 6, 2012|

On this weeks Health and Wellness show, Dr. Alan Glaser is joined by Dr. Matthew Messina from Newton Wellesley Orthopedic Associates. Today's discussion focuses on sports related injuries and children. Dr. Messina served as Team Physician for the University of Maine Division I Ice Hockey and Football Programs. His interests include Sports Medicine, Joint Reconstruction and Fracture Care.

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Man -- man. This is not strictly reserved. Welcome to call them on the show and -- this talk station in game six AB WRKO and I don't think you well and hopefully we. -- And I am pleased to welcome doctor Matthew Messina from new rules -- orthopedic associates. Ducks were seen as one of thirteen or the so -- and who knows whether Phoenix can answer. He specializes in sports medicine hands. -- and I thought we would speak about knee arthritis today Matt thanks for joining us pleasure to be here. So getting right into the need for all of our listeners. If you could just fine -- me in simple terms. So all of our listeners on what are the structure is right inside me. The main structures side in the -- obviously have your femur bone by bone. Which is via opera part of the joint the lower leg is made up of the tibia and the -- bone. In general terms than me is unhinged joint where you slacks or venue -- standard straight and then a that there is some rotation involved as well. Ends as far as injuries that you'll see. Firm when we speak later on about some sports related injuries. Could you just define the ligaments -- and the meniscus follow her listeners and. I'm sure. On the inside with a -- in terms of ligaments you have for a major ligaments you have the rancher who share and poster -- -- ligaments. Which Criss -- in the center of the joint. That provides stability forwards and backwards. I you have the two collateral ligaments the -- quarrel and lateral collateral ligaments. Of those are on the inside and outside respectively. And they're responsible for stability from side to side. In addition to that you have to. -- this guy of the medial meniscus and the lateral meniscus. And those are -- shape two rings of cartilage which act as shock absorbers between the bones. Which helped to disperse stress route to -- but also provide stability. So that we have a patient to we're gonna send over a two year group. Tomorrow Monday morning. -- a patient in their seventies. With chronic pain that's a little script -- the morning. Once you get moving a little bit gets a little bit better with overuse. Them with stairs they find and mixes well. What are the first step you going to do when you're seen -- patient. Well initially the history is most important how the symptoms present how long they've been there. Certainly in that age group at the top peerless might be arthritis. What arthritis is is a wearing away of the particular cartilage. Which covers the bones. Were all born with a certain sickness or with the cartilage over the bone. But overall lifetime and so many miles on the joints just like a tire on a car. Blues trends are the cartilage wears out and eventually. You might end up with a big blowout where the currently just worn down to bare bones. What will the most common symptoms speak. Of someone who's presenting to your office when you suspect in the arthritis. Opinion is one of the most common ones but also stiffness and swelling in the name. And when they come in to see you should these patients expect an X -- -- not necessarily. X rays are actually the first. Diagnostic tests that you would do their very sensitive and specific for picking up. Knee arthritis and we usually have people stand for the X rays. And by looking at the X ray just giving indeed just how much thickness or the amount of space they have between the bones. That can give you an idea of how far they're wearing their knees now. So now we have a patient to. As presented to your office they've had their X -- the history is consistent with -- arthritis. What what is her treatment what are their options at this point. On the initial conservative treatment options. A lot of times will be initially activity modification of there was a particular. Activity that bought on the symptoms. In terms of medications. Things like Tylenol or receive -- offend or some of the over the counter anti inflammatory is the more common ones Ibuprofen. And now -- and which has a leave. Would be helpful for the acute inflammation. In addition to that strengthening. Muscles around the joint will tend to take stress off the joint so a lot of times will prescribe physical therapy. And -- symptoms persist more than 46 weeks certainly. A cortisone injection would be the next more invasive step. For physical therapy. How often confused and expect to go initially. And is it something when you would say that after the got a few times in the -- in their exercises. That they can continue those on their own and is she really continue those for a lifetime. In general. A physical therapy you'll prescribe one to two times we over for a six week timeframe. Most people after two to four visits will usually have a good handle on. The exercises that they can do at home. A lot of times therapist can provide modalities which patients camp provided home which will help people and sometimes the therapy will be extended. In addition to the things that I mention. We're also. The American academy of orthopedic surgeons was also identified weight loss is another thing that people can do hope with arthritic knee pain. Getting back to the Ibuprofen that you mentioned I wanted to remind all of our listeners. That the Ibuprofen medication you do and take on a full stomach. You certainly wanna check with your health care provider on whether you're eligible to take the Ibuprofen. Some patients are in a different risk level where you shouldn't be taking -- and if you're taking over the counter Ibuprofen. -- is a prescription strength. Please understand. -- 400 milligrams of Ibuprofen over the counter is a little different than 400 milligrams. As a prescription. He can often be. -- as a aspect of for the condition you're trading. But understand that there is a difference even with the equal milligrams. Met besides your arthritis we certainly know that. That Wii Sports related injuries especially for summer are younger listeners. For the lacrosse players in the soccer players. Could you tell me some of the more common presenting injuries that you see for a lacrosse players. In in addition to. Injuries such as ligament terrorism and a school tears. Another thing that's inherent with the crossing pairings there. A lot of clavicle fracture is a collar bone fractures. Iranians feel the need how one of these lacrosse players typically present to the opposite what will their initial complaint be -- complaint. On May complain with a knee injury particularly when you're talking about the inter cruise -- ligament which is the more common in injury in the need. Most of the time that happens a non contact the injuries so the athlete will be running down the field. No planet cuts he changed directions. A lot of times -- feel or hear loud pop and immediately have swelling in the name. And that -- they were obviously that players can be shut down immediately absolutely. With the soccer injuries what would you say -- were more common injuries aren't soccer that you say. In soccer. Very similar to answer cruise -- ligament particularly in the female population has been very prevalent. In fact these females are tearing that ligament at a rate of about five to eight times some more than the boys. Com you'll also see me in the school -- in addition to the inter -- Lieberman terrorists. In addition to that which is inherent soccer without wearing a helmet is just head to head collisions -- impressions. Are going up for header for the ball. So. For my. Nine year old daughter Sabrina would you say that when -- when she's playing goalie. That the best thing to do and -- that shark comes is to scream out of the way as quick as possible. Well like anything else god gave us that inherent defense mechanism to put our hands up in front of her face when something's moving slow. I appreciate us to move completely out of the way but I think using her handsome foreign -- a different views. And she certainly quick excellent that works in her in her favor. Let's shift gears from the knee in speak a little bit more about the club regular injuries that you were speaking about lacrosse because I know there's a lot of lacrosse players and if you're listening and if you're not a lacrosse player and you know the I'm. Oftentimes you'll find is that you'll certainly have a family member -- a child or grandchild who's on the lacrosse field it's really you know become very popular sport. Yes so most of the clavicle fractures are in the mid portion of the Clavet call. And usually user from a direct hit with a stick or falling into the field on an outstretched hand. In most adolescents and wanna see adolescence probably lacrosse players less than the age of seventeen. Most of these fractures can be managed with the simple sling or finger -- race. 42 to three weeks until the pain and the swelling subsides. And then just modifying the activity for an additional five to six weeks. And rare instances. Would operative intervention via indicated in that age group. This is doctor -- -- and you listen to the health and wellness show on Boston's talk station same succeed WRKO. I'm speaking with doctor -- scene of Newton was -- a computer associates. They have a great website. It's www. And W a -- dot com -- www. And for Newton W Wellesley. -- orthopedic -- associates. Dot com their phone numbers 6179640024. Against 617964. 0024. And if you wanted to call and for an appointment doctor Messina. Or any of his other twelve associates. The -- Monday morning early and didn't give a call and they're always able to accommodate. For our listeners -- now. I'm gonna ask our producer Kevin what is the phone number for someone calling in is that 617. 2666860. Again. -- -- -- -- -- -- -- -- -- -- -- -- -- -- Maybe an impression that someone is standing -- to answer your call. -- reductions sooner or myself. Some -- let's work our way down your leg in dividends are notoriously -- -- in the -- -- Yeah for me -- soccer player in the lacrosse player and it's. -- where many. Of the athletes this time of year and -- I know this many other sports but for those specifically. Tell us what's in the engine as you'll see in the lower leg. On some of the injuries. -- Woolsey or would say they the most common ones we see. Our stress reactions in the tibia or similar bone which are pretty elude to stress fractures and the tibia or fable a bone. And that's just more overloading the bone to a point where the ball will then break. Another thing that we see is the common or garden variety shin splints it has a new name. I'm -- to deal stress and drummer and TSS. As it's commonly referred to. But that's inflammation. Of some of the softer issues that attached to the inside of the tibia bone and can cause discomfort. Tom another less common thing that we see is exercise induced compartment syndrome. We see that and people who run a lot you may see that and soccer players. And now what that is is a swelling of the muscle groups are compartments. Of the lower leg that's around the bones. And as the pressure increases with inflammation or activity. I can sometimes affect some of the nervous functions of the foot and ankle. And commonly presents with numbness or tingling during. -- Jerrold just some of the stress reactions are condemning to a stress fracture. For our young athletes. What should be a red flag to them or at least the yellow flag went to suspect this. If they're starting to half. Team while their running on the field. And that team is getting worse while their running. With stress reactions and stress fracture in -- fractures holes Boston have. -- even after the activity has stopped. And then they could start to develop pain was just regular walking so that would be a red flag. Heading from a stress reaction to a stress fracture. So if one of those athletes is suspecting that and they're gonna call your office tomorrow morning. How soon should -- ideally be seen if they're having some suggests about the stress reaction. I would say that most of these symptoms should be seen within within one week period. As you know in our office it's never a long way to get in and we have open spots every day for cases like this oh. But I would say definitely within a week. And for that happening whose Reno waiting nick you know day or two or what have you. So they shut down their activity in the interim. Absolutely. Have an old saying in the office of rest is always bass though certainly are modifying activity while. Ends they shouldn't be shy in telling their coats that they're having symptoms either absolutely not mean nowadays there's a lot of pressure not only from coaches the parents and other players and friends. But -- certainly. -- is a protective mechanism if you steal it there's a reason so certainly that has to be respected. Especially in young athlete because. They really reached a young athlete who doesn't have a lot of Wear and tear on their joints. In on their bones. They shouldn't be having pain if you're having -- young athlete you need to take that seriously we don't want you to be a hero we went idiot checks. Again a phone number of new ones who have competed associates. Where have they apply your same day appointments is 617. 9640024. Again 6179640024. -- working our way down the leg. Let's get down into the Inco now and talk about. Ankle pain. And what you wouldn't suspect. In one of our older listeners. Who is you know maybe walking -- for exercise. -- not not our soccer player lacrosse player. Baseball tennis player who gonna say someone is more sedentary. Older they have -- -- was the first step in their valuation many see you tomorrow morning. Mostly the older patients will present with the ankle pain and comes in a variety of forms. Some of the more a traumatic things that we'll see is that development of gal in the ankle joint and that's typically. Presents with swelling in the join the joint will sometimes be red hot. A lot of trouble bending it up and down so that's one of the more common things -- him older population. And they'll come on -- doubt obviously more suddenly absolutely. What would you suspect for -- -- more chronic other than arthritis or is that really our our main differential there via arthritis is always in the differential for. Ball joints but it's it's a very uncommon in the ankle when comparing it than the have. Another thing we'll see if people have flat fee is supposed superior to deal tendinitis. Over a lifetime people can develop pain the generation of the post here T -- tendon which -- the tendon on the inside of the ankle. And a lot of times as people age the -- animal actually rupture like ago. Stands for the younger athletes. For ankle pain the scenario where comes on suddenly. What do we suspect in the -- In the younger athlete most commonly. And ankle sprain of the ligaments on the outside of the ankle is by far the most common type of injury. In the scale -- in mature athlete or the athlete that has opened growth -- it's certainly the growth plate is more vulnerable than the tendons and ligaments around the joint. So that's something. I always think about the younger athlete. This is doctor -- laser and you listen to help them -- -- -- on Boston's stock -- game 680 WRKO. I guess this document Messina of new miles you attributed associates. And again their website is WWW. Dot NW -- dot com. That's www. NW -- dot com if you have a question for doctor Messina during the show. Please call -- to 617. 2666868. Cuts remember your right at WRKO. Again at 6172666868. Men let's work -- -- down mourns her foot. And speak about -- fractures. And specifically getting into the fifth meant a torso fracture. Defenseman time. -- is a very common area on the flip that athletes -- fracture. More commonly the fracture as at the beginning portion of the -- what we called -- -- mall portion. Most of those fractures -- treated with a period of a mobilization is there and cast or cast walking boot. With some limited weight bearing of the most of -- require time to heal. There's another variety of that same fracture which was a little bit more disorder down the -- to the -- parcel and people may have heard of the Jones fracture. And that area the ball in the blood supplies -- lasso the healing is not as predictable. In Austin and athletes -- recommend surgery. To fix this fractures. And that -- reduce the disability for the athlete and get him back on the field sooner. For the men and Tressel fracture that's not as severe as the Jones fracture. And that -- is going to be in the cast are walking boot how long can we tell them to expect to be up from their activity. I usually at least a period of six weeks but often times up to eight weeks. And for the Jones fracture or more variable of course as you stated. What's the worst case scenario with that fracture. After they're having surgery. Well after surgery. There's always a possibility of complications. With a knee surgery. But sometimes the fractures will not heal as predictably in sometimes you have to revise or reduce the surgeries. A lot of times the screws that we use and high level athletes particularly. Have you football players can sometimes break the hardware of the screws and that adds another. Problem to deal with down the road. But if the surgeries stung. Without complication. Most athletes and expect to get back on the playing field sooner than if they didn't have surgery. -- Any other fractures of the -- that you see commonly that would be helpful for our listeners to hear about. The only other common one that we see -- just stress fractures in the met Parcells and those are typically. In the more middle portion of the floater towards the -- ball of the foot. Once again they're treated like stress fractures any worlds in the body a period of limited weight bearing and given just time. And elevation and -- is that playing a role here as well for the healing. Absolutely if the more the people on their feet the more gravity will pull fluid into the lower leg or foot. So elevation has always recommend recommended especially acutely within the first 22 to 72 hours. I saw during that period as well. Sorry that's great. That I thought we'd the switch gears now and work our way up. The body and speak about the shoulder. And specifically for some of our older listeners. We know that rotator cuff injuries. Certainly can be a way that the shoulder pain will present TO. Soviet -- and a little detail there and what the older patients. We should be looking for and when they should be contacting your office. Will rotator -- Aziz is. Very common anytime after the age of 35 or forty. Most of the time when people presenting the office it's a -- shoulder pain that starts without any sort of trauma people notice. Team reaching up into the cabinet to put their dishes away. Are reaching behind their back to scratch putting their jacket on sometimes reaching out the window of the car to get a parking ticket. All those things wolf precipitate. A pain in the rotator cuff. In terms of the structures that can inflame. The rotator cuff has made up before tendons that attached to the upper arm Boehner humorous which as the ball of the shoulder joint. On the tendon itself can get inflamed and that'll be and the variety of tendinitis. There's also a fat pad in the shoulder called the Bursa. And the function of the -- is to lubricate and provide nutrition of the tendons. I can also become inflamed. Stands global some of the team and speak for a rotator cuff tendinitis -- in my definition misinformation their. You know -- Grossman as the patient to -- the area and try to avoid the aggravating inciting movement that's making it feel worse just for the comfort. Other net in the -- the inflammatory medication were the other two minute vice. Our physical therapy is definitely included in the first line treatment. Often times will give people injections into the verso with cortisone -- and which helps to. Not only diagnostic -- tell -- of the pain is coming from that area but therapeutic plea lot of times we'll help with the pain. Bomb before the age of sixty it's very uncommon for people to just have a traditional or spontaneous rotator -- terrorists. After the age of sixty. That incidents will increase. So when myself one of my nurse practitioners over at Wellesley primary care medicine. Has a patient with rotator cuff tendinitis. And we've already treated them with ice and rest and anti inflammatory medication. And now they've gone to your office and it kind of therapeutic injection as well. -- they've had physical therapy in this still not doing well we're the next steps that you do from that point. I'll the next steps will be some baseline X rays to look at the drawing to rule out things like arthritis at the ball and socket -- what we called the -- you -- joint. Also near where is the collarbone clavicle meets the chromium boom which has the top of the shoulder blade or the Romeo particular joint. If things are normal and -- perspective we would recommend and samurai scanned. So look at the -- issues around the shoulder in particular of the rotator cuff tendons. Now shifting to the younger athletes. For shoulder injuries were certainly we will see that in baseball. In in my process. I know my seven year old son who's playing baseball a's lefty and throws heat. But that this actually get an opponent -- baseball discussion. Ferraro for everyone missing was a baseball player. For protecting the shoulder and the arm I know that is the school of five years and years ago when I would play. Was that you shouldn't be throwing a curve ball until you -- certain needs because of the risk you could do to his shoulder. But now we're finding with more recent research. Is it's really the pitch count. And a number of pitches that you have to worry about rather than throwing different speed and you know crew balls when have you that actually would you say. I think that's -- very accurate. We know from Major League pitching data. That the rotator -- starts to break down somewhere between eighty and a hundred pitches. And that's why there's the emphasis on the Major League level about pitch counts. A lot of that has been transferred down to the lower levels college high school in Little League. Ends in terms of throwing a curve ball I I don't believe that the data is conclusive that occur ball will damage your arm. But I will say that most of the pitching instructors. Out there. Will emphasize. Younger athletes mastering their fastball first and throwing them for strikes greater than 75%. Of the time. Before they start to try -- alternative pitch. At the younger level the pitch that most of those people as the Davis during a change up as opposed to a curve ball. And -- received the on the arm the chains -- still it's still pretty safe -- think. Most that most of the pitching coaches believe that's safe for them. -- great and let's say we have a baseball player now who comes to your office. And the shoulder pain. What are the first steps that you're going to take and evaluating them and can expect next race. Well if it's the adolescent athletes. An athlete less than say fifteen years of age certainly X rays of the shoulder and elbow. At this point in their career the growth plates at the humorous bone as well as at the that this -- of the humorous bone at the elbow. Are still open so the tendons that attached to those growth plates are stronger than the growth plate. So the two things that we see more commonly our little legal little leaguers shoulder and little leaguers elbow. Which is essentially the tendons pulling traction on the gross debates and causing pain. -- most of the time those entities are just treated with rest. Anti inflammatory his eyes and physical therapy. And how much -- do you think that player when you take off if they have you know somewhat moderate case. I would tell you a minimum two weeks but often times up to scoring six weeks. We spoke about the lacrosse player or were up -- that shoulder area and speaking about particular fractures. What what traumatic injuries do you see with baseball would you say the most common. Rarely in baseball you can sometimes -- humorous fractures. And that's just a pitcher who's throwing very forcefully or violently. And they put such a torque on the -- that sometimes will spontaneously. Break. In some cases the -- might be predispose. To breaking often times. Bony tumors are are found that. This is doctor Alon -- you're listening to help them on this show on Boston's talks vision. Seems succeeding WRKO. My guess is doctor -- missing now he is one of thirteen orthopedic surgeons and new -- orthopedic associates. They have a great website. Www. NW always done. Against www. -- using W -- award. Many associates dot com. They're big on numbers 617964002400000617964. 002 before this started missing a mention as always in the appointments available. For any of our athletes revenue injury this weekend and we hope that none of the deal but the reality is we know that sometimes some veto. Give their office call and we'll take your view on Monday. That let's just go through could become an awful lot of material for a listeners and I know that it's been very very helpful to all. Everyone tuning in as well. Going back to the arthritis. If we had to pick out. For the older population and welcome that over the ages 75. Just for the sake of a defining some analyze it drains. What are the three most important take home points to our listeners. About knee arthritis. Over the age of 75. I think. What should be emphasized is maintaining flexibility. Emotion at the joint with stretching. Certainly strengthening of your quadriceps muscles and hamstring group which is on the back on the side. To help take stress off the area. And -- certainly anything. Injunctive like an anti inflammatory or Tylenol. On -- cope with the discomfort. Are certainly of X rays would show advancing arthritis the more common procedure that's recommended is a total knee replacement. And that is a very viable option for people -- -- age group to unpredictably relieve their symptoms of arthritis. Getting in tune in knee replacement and you know that that's a whole a whole other so we'll dedicate to that in the future. But with with the respective knee replacement. Or any joint replacement it should really be noted that in the year 2012. That there are so many medical advances. That. We even -- joint replacements and people in their ninety's. -- If you're in -- ninety's. In -- having pain and it's affecting you with daily life. You owe it to yourself to get into new laws do with the PX get a consultation. And see if your candidate for these short replacements he may be pleasantly surprised. That you are and the recovery and because of the technology. Is much better than it was -- -- years and years ago and decades ago. So I highly advise used to get it under consideration. Not getting you know into the need for the sports related injury in -- speak about specifically soccer. Trauma from soccer. For the -- toss again the most common injuries you'll see. And the three most important take home messages. To the athlete who was playing this weekend. Who thinks they had a bad knee injury. Well like we said before the common. Knee injuries that we see our injuries to the inter cruise ship ligament. Injuries to either the medial or latter role menace I. Or sometimes show us a simple contusion and even need to hit more -- simple sprain more than he has been twisted. I think the more important things that you can do for. Preventing ACL and -- school injuries. Is proper stretching before activity. With an emphasis on strengthening of the muscle groups around the -- Ankle pain we spoke about the most acute. Presentation. Of ankle pain. Is -- we're gonna consider Garnett situation. Is that something where if a patient. This week and experiences. Sudden severe ankle pain that's really appropriate to start with your primary care physician and safer statements. That's a fair statement a lot of tons of the pain is that bad a lot of people will present to the emergency room and that's very common scenario that we see as well sometimes an acute -- attack can be that debilitating. Stands. For the more chronic. Ankle pain -- SP -- arthritis is an every differential. Putting into us not them the most common. To a -- -- the for the clinic -- team what you're thinking. Well certainly starting out with some baseline X rays to get a picture of the ankle would be recommended. A lot of the pain around the ankle can be contributed to the tendons that -- the ankle and help let's move. And certainly physical therapy is one of the staples in treating chronic ankle pain. Another thing that would be considered depending on the position of this but. The arch of the foot or sonics are another consideration. Getting into the foot and that was a great -- We spoke about -- torso fractures in about Jones fractures of the four which -- the more severe scenario. Tell us little the most important take home messages for the foot fracture -- -- listeners. Well any time you're developing -- particularly on the -- border of the flood. That should always be respected. And certainly if you're having -- just regular walking a regular weight bearing. It's certainly you know worth it to call your doctor -- specific search and foreign X ray. We have a saying in orthopedics a picture's worth a thousand words and certainly X rays are done very routinely and I'm very inexpensively. And they provide a lot of good information. And the extras have been reading your office correct that's correct so the pace to move really. -- commend their for their visits and have everything done a lot of times all in that same visit and don't know there actually findings before they leave. Absolutely we have digital X ray computers and every exam rooms so when people return from the -- race week. Other able to look at their X rays in the exam room with a physician. Immediately. That is great. Getting up into the shoulder again we spoke about the rotator cuff tendinitis. In the older population. The most important takeaway -- is there. On the most important take home message for the over sixty crowd. Would be if you were having difficulty reaching above shoulder level -- over your head. -- certainly that's an ominous sign that you may have developed in nutritional a rotator -- terror. And certainly we'd like to know about rotator cuff tears sooner than later. Because in the early stages or acute stages. Rotator cuff tears are very -- terrible people have very good long term outcomes when -- repaired. On the problem we run into is when people that collect the symptoms that they're feeling. The rotator cuff tears retracting scorer and then they're not re terrible. And that's a situation which we refer to as routier Costner thrown apathy. That's a very difficult situation to address down the road to recognize. What is that time frame where if someone is suspecting. They rotator cuff tear. The ideal time for him to not exceed. If they -- the surgery in the ideal timeframe within the first six weeks but six to twelve weeks would be the upper limit. And again getting into the more acute injury of the shoulder for the younger population. Tell us again those most common injuries hands. A few little bullet points about those as well. All in terms of. The bony joint injuries like we touched upon before mid -- clavicle fracture is a very common. Strains and sprains of the a Romeo chronicler joints which people often refer to a shoulder separations. The other injuries we see an athletes certainly are if their shoulders this -- the war some blocks. Sometimes you'll see liberal injuries of the Lieberman is the cartilage that surrounds the socket of the shoulder joint. And those are common injuries we see as well. We spoke about one common treatment. Is the use of -- point -- medications. Again just as reminders. And which a lot of our all of our patients over Wellesley primary care medicine. Please take these medications on a full stomach. Please check with your provider if you're OK to tape when these medications. Sometimes there's risk that -- Contra indicated usage. And also please understand that the over the counter strength. Is not exactly equal to a prescription strength. Even when it's similar milligrams. But he at all from the over the counter strength will suffice. This is doctor Aaron -- you've been missing to a halt the moment so on Boston -- station. -- succeed WRKO. -- one of the thing doctor Mehmet singing and for joining us on a Sunday afternoon. And educating us on the need. On the local before in the shoulder that we covered an awful lot Nia in the session I -- it's been -- helpful to all of our listeners so thank you again. You're very welcome I'm glad to be here. Again that is one of thirteen positions of need Mozilla competed associates. There website the and is www. NW only dot com. Again www. NW -- dot com their phone number is 617. 9640024. Against 6179640024. For all of our listeners. We want to be sure that your being careful with your sports activities. And even for those who are not athletic. To be careful be aware of your body and if you have what -- these conditions we spoke about any other orthopedic condition but you know it's its attention. Name them please give our call to love your computer associates. -- 618964. 0024. We wish you always happy we. Oh yeah I look forward to all of you tune in to the show next week. Again Sunday at 5 PM Dan thanks for listening.